Download MBBS Acute Pancreatitis Lecture PPT

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? An acute condition presenting with abdominal

pain usually associated with raised

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blood/urine pancreatic enzyme as a result of

pancreatic inflammation.

? Reversible pancreatic parenchymal injury

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associated with inflammation.
ACUTE PANCREATITIS.

? PATHOPHYSIOLOGY?

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? Premature activation of

pancreatic enzymes within the pancreas.

? Anything that injures the acinar cells and impairs

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the secretion of zymogen granules or damages

the duct epithelium and thus delays enzymatic

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secretion , can trigger acute pancreatitis.

? Once cellular injury has been initiated , the

inflammatory process can lead to pancreatic

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oedema, haemorrhage, and eventually necrosis.
ETIOLOGY.

? acute pancreatitis-

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? As an acute inflammatory process of the

pancreas with variable involvement of other regional

tissues or remote organ system.

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? Two major causes are--
? Biliary calculi(50-70%)
? Alcohol abuse (25%).

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? The remaining causes may be idiopathic or rare.
? Approx. 25 % cases of Acute pancreatitis.
? Act by increasing the synthesis of enzymes by

pancreatic acinar cells.

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? Over-sensitization of acini to cholecystokinin.
? SMOKING-
? cigarette smoking is an independent

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risk factor for acute and chronic pancreatitis.
HYPERTRIGLYCERIDEMIA.

? Serum concentration above 1000 mg/dl ppt. Attacks of

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acute pancreatitis.

? A triglyceride level higher than 2000 mg/dl confirm the

diagnosis of acute pancreatitis.

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? Hypercalcemia-

Hypercalcemia of any cause can lead to acute

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pancreatitis.

? Deposition of calcium in the pancreatic duct and calcium

activation of trypsinogen within the pancreatic parenchyma.

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Causes of Acute pancreatitis.

? Gall stone.
? Alcoholism.
? Abdominal trauma.

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? Hyperparathyroidism.
? Hypercalcaemia.
? Autoimmune pancreatitis.
? Viral infection.
Gall stone pancreatitis.

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? Transient blockage of common bile duct--

reflux of bile into pancreatic duct and impair

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flow of normal pancreatic juice ?premature

activation of pancreatic enzymes within duct

system.

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CLINICALLY.

? Presenting with 2 of the following 3 criteria

? Epigastric pain consistent with pancreatitis.

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? Serum amylase or lipase level greater than 3

times the upper limit of normal.

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? Radiologic imaging consistent with pancreatitis(

usually CT or MRI ).
HISTORY TAKING.

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? 1.Abdominal pain-
? Site-Diffuse,upperabdominalpain.
? Onset--sudden.
? Character?Boringpain.

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? Radiation---Radiatetoback.
? Associatedfactor-Nausea,vomiting...
? Timing--Painescalatesinintensityandpeakswithin

10-20minutesofonset.

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? Elevationoftemperatureisoftenisacute

pancreatitis.
Abdominal Examination.

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? 1.Inspection-- abdominal distension.
? 2.Palpation--
? Hepatomegally.
? Tenderness.

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? Cullen sign.(Blue

discoloration around umblicus)

? Gray turner sign. ( Blue red

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purple discoloration around flank).

? Peritoneal sign
? Rigidity and Guarding.

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? Percussion--
? Dullness suggesting ascites.

Auscultaion-

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? ascultate the abdomen for hypoactive

or an absent bowel sound.

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INVESTIGATION.

? Biochemical---

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? Serum Amylase increase 3x than

normal or more than 1000IU/mL.( Peak within

the first 24 hrs after onset of symptom.

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? Serum lipase has longer half life thus more

useful in delayed case.

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? Serum lipase: more sensitive and specific for

pancreatitis than Amylase.
Amylase and Lipase.

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? Elevated serum amylase and Lipase levels in

combination with severe abdominal pain. Often

trigger the initial diagnosis of acute pancreatitis.

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? Serum lipase rises 4 to 8 hrs from the onset of

symptoms and normalise within 7 to 14 days

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after treatment.

? Marked elevation of serum amylase level during

24 hrs.

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? If lipase level is about 2.5 to 3 times that of

Amylase, it is an indication of pancreatitis due to

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Alcohol or gall stone.
Biochemical investigation.

? Serum amylase-
? Levels turn normal after 48-72 hrs even

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with the continuing of pancreatitis, serum lipase should be sent
that remains high for 7-14 days.

? Persistent elevation suggests pseudocyst,

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pancreatic abscess or non pancreatic

cause(intestinal obstruction, mumps,narcotics).

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? Serum lipase- Remains elevated for 7-14 days. It is diagnostic.
Serum Lipase.

? The sensitivity of serum lipase is similar to that

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of serum Amylase and is between 85% to

100%.

? Lipase may have greater specificity for

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pancreatitis than amylase.

? Serum lipase always is elevated on the first

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day of illness and remains elevated longer

than does the serum amylase.
Other laboratory Findings.

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WBC- 15000----30OOO

Leucocytosis
GLUCOSE HIGH

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Hyperglycemia in severe cases.
BUN MAY BE ELEVATED

SERUM CALCIUM MAY BE LOW IN 25% OF CASES.

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AST,BILIRUBIN,ALP ARE TRANSIENTLY ELEVATED,ALBUMIN IS LOW IN

10% OF CASES AND INDICATE SEVERE PANCREATITIS
ELEVATED LDH SUGGEST POOR PROGNOSIS

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and indicate biliary tract disease.
Assesment of C-reactive Good indicator of progress.

ABG shows HYPOXIA.
Other cause of increased serum

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Amylase.

? Renal failure.
? Liver cirrhosis.

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? Peritonitis.
? Ruptured ectopic pregnancy.
? Salivary gland inflammation(parotitis).
other blood test.

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FULL BLOOD COUNT

Elevated Leucocyte count for Ranson's

criteria and to predict prognosis.

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LFT

To asses cause of pancreatitis/obstructive

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jaundice.

Random blood glucose

Damage to beta cells interferes with insulin

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production causing Hyperglycemia( in severe

cases).

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Serum calcium

Hypocalcaemia suggest saponification.
Ranson score

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predicting the severity of acute pancreatitis.

? At admission
. age in years > 55
? WBC count > 16000 cells/mm3.

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? Blood glucose > 200 mg/dl
? Serum AST > 250 IU/L
? Serum LDH > 350 IU/L
? At 48 hrs
? Calcium- < 8 mg/dl

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? Hypoxia (po2 < 60mmHg)
? Increased BUN
IMAGING ?ULTRASOUND.

? USG should be performed within 24 hrs in all

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patient.

? To detect--- Gallstones.
? To rule out-- Acute Cholecystitis.

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? To determine whether the common bile duct

is dilated.

? To evaluate change on pancreas i.e. Edema.

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Mass in pancreas.
CT SCAN.

? Not neccessary for all patients.

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? May reveal pseudocyst or

abscess.(complication of acute pancreatitis).

? CT Findings--

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? significant swelling and

inflammation of the pancreas.
Management Acute pancreatitis.

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? Mild Acute pancreatitis--
? 1.Nill by mouth.
? 2.Fluid resuscitation-4 pint.
? 3.Analgesia-IM Tramal 50mg TDS.
? 4.Treat underlying cause.

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? 5. NO role of antibiotic.
Severe Acute Pancreatitis.

? Admission to ICU.
? Oxygen supplementation.

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? Analgesia.
? Aggressive fluid rehydration.
? Monitor vital sign.
? Monitor haematological and biochemical

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parameters.

? Nasogastric drainage.
? Antibiotic prophylaxis--imipenem, cefuroxime.
CASE 1.

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? 56-years-old obese man who is in cardio-

respiratory distress. While reviewing the

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patients record you see that he has a four-yrs

h/o alcohol abuse and he was admitted to the

hospital via the emergency room 36 hrs

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previously with a two day h/o Epigastric pain

and vomiting.........
On admission vital sign..

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? Blood pressure-------95/30
? Pulse rate -------110/min
? Respiratory rate -----28 breath/min.
? temp. ------38.6

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? Abdomen was distended and diffusely tender.
? No Bowel sound were heard.
Laboratory data included:

? WBC count----18,000/ml

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? Blood glucose---220 mg/dl
? Calcium -------- 7 mg/dl
? Creatinine -----2 mg/dl
? LDH -----980 IU/l
? CRP ------15 mg/dl

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? Amylase ---180 IU/l
? Lipase 1540 IU/l
? The serum was Lipemic.